Click here for a chart showing the state's increase in painkiller consumption over the past decade.

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HUNTINGTON, W.Va. -- In the emergency room at Cabell Huntington Hospital, Dr. Allen Holmes sees patients jump off the bed at the lightest touch to their backs. He hears bizarre excuses.

"My doctor is out of the country for two years," they say. "My dog ate my pain medication."

They check in to the ER for one reason: They want pills.

As head of the hospital's emergency department, Holmes finds himself on the front lines of West Virginia's prescription drug abuse epidemic. In the four years since he's been doing this work, he's watched it get worse.

He sees people in their early 20s whose doctors have prescribed them the highest possible doses of narcotic painkillers. He sees old people trying to play the system. He suspects some are addicted, while others want to sell the pills to make ends meet.

Holmes thinks he's too skeptical sometimes.

"And I feel bad about that," he said. "But on the other hand, I feel like I would be contributing to the problem if I leaned too far the other way."

Some West Virginia doctors have been accused of running alleged "pill mills" where people get addictive medications without proper exams.

Well-meaning providers are grappling with a host of challenges in prescribing powerful prescription drugs.

"It's really a complicated issue because we need to have balance," said Dr. Alvin Moss, director of the Center for Health Ethics and Law at West Virginia University and the West Virginia Center for End-of-Life Care.

These medicines help cancer patients suffer less, he said. They help elderly people die with their pain controlled.

The drug abuse epidemic, though, has made some doctors afraid to prescribe them.

"I talk to a lot of doctors now who say, 'I just don't prescribe opioids in my practice," Moss said.

There's no question, though, that West Virginia's consumption of the most abused opiate painkillers has skyrocketed over the past decade.

A Gazette review of data from the federal Drug Enforcement Agency, combined with Census figures, shows that between 1999 and 2009, West Virginia's per capita consumption of these drugs has soared:

* Oxycodone: 294 percent increase

* Hydromorphone: 319 percent increase

* Hydrocodone: 296 percent increase

* Fentanyl: 348 percent increase

* Morphine: 199 percent increase

* Methadone: 462 percent increase

Consumption of two opiate drugs -- codeine and meperidine -- declined by about 50 percent each during the time period. Many hospitals have stopped using those drugs because of side effects, Moss said.

Data for every state could not be obtained from the DEA for this time period. But West Virginia's not the only place with a growing demand for pain medicine.

Nationwide, Americans' use of opiate painkillers -- synthetic versions of opium that include OxyContin and Vicodin -- has increased at least 10-fold in the past 20 years because of a shift toward more aggressive pain treatment, according to the federal Centers for Disease Control and Prevention.

"If only the people that needed pain medication had it available to them, there wouldn't be a [black] market," said state Chief Deputy Attorney General Fran Hughes, whose office sued the makers of OxyContin in 2001 and received a $10 million settlement three years later. "There's obviously a supply that exceeds the legitimate demand."

Evan Jenkins, a Democratic state senator from Cabell County and director of the West Virginia State Medical Association, calls prescription drug abuse "one of our most challenging health and criminal issues."

"If we squeeze this so much and make it too restrictive, we are going to have people suffering unnecessarily," he said. "This is a delicate balance between being able to maintain its availability and its uses in an appropriate manner, and to also go after, strongly, the dark side."

Dr. M. Khalid Hasan, a Beckley psychiatrist and member of the state Board of Medicine, puts it more bluntly.

Some of his colleagues' careless prescription practices frustrate him. "They're writing [prescriptions for] too many damn narcotics."

'The fifth vital sign'

Every room in Holmes' department has the same sign: How do you rate your pain?

Many physicians used to be leery of prescribing narcotic painkillers. Things changed in the 1990s.

Both the American Pain Society and the American Society of Anesthesiologists released guidelines encouraging expanded use of opiates to manage chronic pain.

West Virginia and other states passed laws saying doctors could not be disciplined or criminally punished for treating intractable pain with controlled substances, even if the dosage exceeded the average dosage, as long as they practice within accepted medical guidelines.

The Veterans Health Administration launched a campaign called "Pain is the fifth vital sign." The agency told its doctors to ask patients to describe their pain on a scale from 0 to 10. Later, the Joint Commission, which accredits health-care organizations, issued guidelines requiring hospitals and nursing homes to regularly measure patients' pain.

During the same period, pharmaceutical companies aggressively marketed opiate painkillers such as OxyContin.

In a typical 10-hour shift, Holmes sees about 25 patients. Between two and four are so-called "drug seekers." Some want anti-anxiety medications like Xanax. Most want opiate painkillers.

Many drug seekers say they're allergic to all non-narcotic painkillers, Holmes said. They ask for a specific drug, like Lortab or Vicodin. They exaggerate symptoms of pain. They relax on the bed, chatting on a cell phone, and then writhe when the nurse walks in.

Holmes can't measure his patients' pain with a thermometer or stethoscope.

When someone complains of excruciating abdominal pain, Holmes must rule out any possible emergencies, even if he suspects they're faking. He must order expensive tests. A CT scan costs $5,000. He and his patient could wait hours to get the results.

With doctors stretched thin, some doctors think writing prescriptions is the easy way out, Holmes and others say.

Dr. Carol Foster, a Charleston neurologist specializing in headaches, calls it "express lane" medicine. She practiced in Arizona for 25 years before she returned to her native West Virginia nearly two years ago. She was stunned by the state's prescription drug abuse problem.

"I was so excited about coming home. And within a month of coming home I thought, 'oh my lands, it's a war zone,'" said Foster, who works at Charleston Area Medical Center's Neurological Services. "I don't have any other words than a medical war zone."

She can't believe how many medications some patients take: Painkillers, anti-anxiety medications, sleeping pills, muscle relaxants.

"I can't imagine swallowing that many pills a day," she said.

Pain pills can make headaches worse, she said.

"Giving pain pills to headache patients is like giving Oreos to diabetics," she said. "They feel better for a few minutes and then they get sicker."

Foster works to determine the cause of her patients' headaches. She encourages behavioral changes, like eating a healthy diet and exercising.

"People are just medicating pain without figuring out why" they hurt, Foster said.

Foster works as an on-call neurologist for the emergency room at night. Like Holmes, she sees drug-seekers of all ages.

"The thing that breaks my heart is the grannies," she said.

Some live with grandchildren who abuse or sell their pills, she said.

Many hospitals survey patients and tie some doctors' salaries to "patient satisfaction scores," Holmes said.

"So if I don't prescribe a patient a medication that they want and they were the patient that gets the survey, " he explained, "they're going to say that I'm a terrible doctor, that we're a terrible hospital, that they didn't get good care."

Physicians need to learn more about the nature of addiction, said Dr. Louis Baxter, president of the American Society of Addiction Medicine.

"Pain pills do not cause addiction," Baxter said.

Research shows that many factors can increase risk for addiction, including genetics and a person's family environment.

Doctors who prescribe pain medications should pay more attention to patients' predisposition to addiction with substance-abuse screenings, Baxter said. "If physicians start to pay more attention to a person's susceptibility, then right there you can begin to be more careful about to whom you are writing prescriptions."

Drug monitoring program could do more

Both doctors and police in West Virginia say that certain policies have helped cut down on "doctor shopping," where patients visit multiple providers for prescriptions.

The state Board of Pharmacy runs a database where doctors can check where their patients have been filling prescriptions. The system has limitations:

* Doctors don't have to check it before writing prescriptions. About 81 percent of doctors surveyed say they do, but only 18 percent do it every time they write a prescription, according to an article Moss co-authored last year for the West Virginia Medical Journal.

* The system isn't linked to surrounding states' databases, though there is talk of doing so.

* By law, police and the state medical and pharmacy boards can only access data during an open investigation. A new report from the state Legislative Auditor's office recommends that lawmakers change this so that investigators can "red flag" unusual prescription practices and potential doctor shopping.

"People who are bent on abusing drugs are very clever, and as hard as we try, they're going to always find a way to get around the system," said Moss, who is a kidney doctor and palliative care specialist.

He remembers one patient who came in complaining of kidney stones. "She had blood in her urine. I gave her a prescription."

A nurse noticed that the woman didn't have a Band-aid on her finger before she slipped into the restroom for her urine sample. When she emerged, she did.

She had cut her finger to let it bleed it into the cup.

"Somewhere along the line, she learned what she should do," Moss said. "She fooled me."

Coming Sunday in the Gazette-Mail: Why are pill mills so hard to shut down?

Reach Alison Knezevich at alis...@wvvgazette.com or 304-348-1240.

This series was conceived and produced as a project for The California Endowment Health Journalism Fellowships, a program of the USC Annenberg School for Communication & Journalism.